CROSS-DISCIPLINARY COMPETENCY AND
PROFESSIONALIZATION IN DISASTER
MEDICINE AND PUBLIC HEALTH
Frederick M. BURKLE, Jr.a, James M. LYZNICKI b, and James J. JAMES b
Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts and Woodrow Wilson
International Center for Scholars, Washington, DC.
b
Center for Public Health Preparedness and Disaster Response, American Medical Association, Chicago, Illinois
a
Abstract: Unfortunately, the response to humanitarian crises and large-scale natural
disasters worldwide have shown consistent failures in coordination, intervention and
documentation of impact outcomes. The response to the Haitian earthquake of 2010
catalyzed the international community to address these shortcomings and
requirements for greater accountability, stringent quality performance oversights,
documentation and reporting, and a recognized process leading to professionalization
of the humanitarian community. Evidenced-based studies indicate the need to use a
cross/multi-disciplinary approach to developing competencies leading to curricula
and course development, and eventual certification and registry of providers. This
chapter discusses the current processes by which these issues are being addressed.
Keywords: Disaster medicine; Humanitarian assistance; Training and education;
Competency, Professionalization
Introduction
The demand for better coordination and control is heard during and after every major large-scale
national disaster and international humanitarian crisis[1]. Recent large-scale disasters, such as the 2010
earthquake in Haiti and the Asian Tsunami that directly impacted twelve Indian Ocean countries, have
revealed "unacceptable practices in the delivery of emergency medical humanitarian assistance[2]." In
particular, questions concerning competencies among some of the deployed Foreign Medical Teams
(FMTs) have been raised including current guidelines that were found to be "limited in scope" in meeting
demands expected of them[2]. These findings have prompted the international community to call for
"greater accountability, stringent performance oversight, reporting, and better coordination," especially in
health services[3]. Further post-crisis discussions among international stakeholders led the United
Nation's Inter-Agency Standing Committee (IASC) and their Global Health Cluster Policy and Strategy
Group to call for immediate debate and action focusing on unmet needs and concerns[3]. Additionally,
the IASC addressed the need for the development of an international register of FMT provider
organizations that would include detailed information on the composition of FMTs and the types of
services they provide[3]. Separately, the international humanitarian health workforce community has
launched a concerted effort to develop a blueprint for professionalizing humanitarian health care
assistance and certification of individual health care providers based on disaster-specific professional
health- related skills and cross/multidisciplinary humanitarian health core competencies[4].
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This chapter discusses evolving efforts to improve the internal quality performance initiatives of FMTs,
and to develop competency-based education and training leading to professionalization of providers
practicing disaster medicine, public health preparedness, and humanitarian health care in crises. Both
civilian and military providers of disaster and humanitarian crisis response, along with the nongovernmental, private governmental, military led civil action units, and international organizations that
represent them, share in the responsibility to ensure that cross-disciplinary, competency-based knowledge
and field-related tasks are practiced with the highest standards of care.
1. Improving Quality Performance of Foreign Medical Teams
It is recognized that FMTs represent the primary focus of organized health care during major
disasters and humanitarian crises. These medical and surgical reams, while collectively referred to as
FMTs or Foreign Field Hospitals (FFH), in reality arise from both national and foreign health care assets.
Until recently, the responsibility and monitoring of the internal quality performance of the FMTs were left
to the teams themselves. For the most part, quality performance is not routinely monitored by FMTs
although highly established teams such as those fielded by Medecins Sans Frontieres (MSF) or 'Doctors
Without Borders', the International Committee of the Red Cross (ICRC), and International Medical Corps
(IMC), to name but a few, all enjoy robust internal monitoring, standards of care protocols, and data
gathering capacity.
The 2010 Haiti earthquake response provides a pertinent backdrop for discussion of FMT response issues.
Data from the Health Cluster Bulletin in Haiti reported that in the "health sector alone, 390 agencies",
mostly international, were registered with the Health Cluster, which served as the external coordinating
mechanism. Admittedly many health providers did not register[5]. The quality of these teams varied
greatly as did those of individual health care providers. Additionally, concerns surfaced that many
providers of humanitarian services were mostly under the age of 30 years and this was their first disaster
event experience. This being said, the response to the Haiti earthquake was fairly typical of what is
experienced during other worldwide disaster events. Anecdotally, more than 70 FMTs were said to have
participated in care but actually only 44 were identified as having deployed in the first month[6]. World
Health Organization (WHO)/Pan-American Health Organization (PAHO) guidelines emphasize that the
FMT's primary role from days 3 to 15 is to fill the gaps in emergency medical assistance resulting from
the large number of casualties or the inability of the local health services to respond to normal
emergencies[7]. Essential requirements of the FMTs are to[8]:
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Be fully operational within 3 to 5 days,
Be self-sufficient with minimal need for support from the local communities,
Have basic knowledge of the health situation and language and respect for the culture,
Include health professionals in selected specialties,
Ensure capacity for sustainability, including appropriate technology, and
Ensure a detailed agreement between recipient and donor as to responsibility for all costs.
Of the 44 FMTs, only "25% adhered to essential deployment requirements and none followed the
full requirements of WHO/PAHO"[6]. Due to the lack of data and transparency, it proved "impossible to
determine to what extent the first wave of FMTs did any good"[6]. Such findings are not uncommon.
Increasingly, there are calls for internal scrutiny of all providers, both those who arrive alone and those
deployed in established or nascent medical teams. Lessons learned from the Haiti earthquake experience,
and other crises, suggest that the process to ensure quality improvements of health services and standards
of performance should be undertaken immediately within the teams and by professional individuals that
comprise these teams. It was observed that, "the Haitian system was fragmented, under-resourced, and
failed to provide access to basic health services in the years before the earthquake. The disaster
compounded these effects resulting in a massive humanitarian crisis on a scale previously unseen by even
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seasoned humanitarian workers[9]." In addition, "many of the providers of health assistance – both
Haitian and international – provided excellent care under very difficult situations, though there was an
absence of a transparent system to link these different providers, or to be able to move patients from one
service to another. For instance, to move patients who had undergone an amputation to a provider who
could organize for rehabilitation or prosthesis fitting"[9]. Internal health care requirements that require
attention for FMTs include, at a minimum[10]:
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Ensuring professional and ethical standards,
Accelerating deployment capability and capacity,
Matching services with supply and demand,
Creating a register of FMT provider organizations,
Establishing teams by specialty, experience, services, and bed capacity,
Standardizing data collection and reporting,
Ensuring that procedures are performed only by those licensed to do so in their own country,
Ensuring that FMTs are staffed by personnel with experience in humanitarian settings, and
Implementing processes to supervise less experienced personnel.
A recent study on emergency surgery care in developing countries identified 185 studies listed in
PUBMED/MEDLINE/EMBASE but in only 11 was the data collection adequate enough for peer review
documentation. Understanding the outcome impact of procedures and adapting to standard documentation
of data formats to show evidence of their outcomes is essential for all FMTs and the information that
must be forwarded to the Health Cluster[11].
2. Professionalization of the Humanitarian Health Workforce
When the above internal FMT requirements are addressed or accomplished, collective attention naturally
shifts to the larger and more critical issue of professionalization, which has been debated for decades
within the community of humanitarian health providers. Because of the recurrent service problems
encountered in these crises, it is understood by the humanitarian community that a system of
"accountability, quality control, reporting, certification, and coordination is inevitable[3]." Both the
humanitarian community and the practitioners of humanitarian aid have this moral and ethical obligation
to the beneficiaries of care. What we provide to citizens in the countries we practice should not be any
different in quality performance than what we guarantee to those in need in disaster and humanitarian
crisis events. Granted, providers will practice in very resource poor settings...but this does not alter the
fact that all practitioners must follow accepted standards of care. We are fortunate to have guidance
available through peer reviewed standards of care publications [12, 13, 14].
A legitimate question is "why professionalization now?" About 3 decades ago, an informal survey
of NGOs suggested that only 2% to 4% of aid workers desired professionalization [4]. Over the ensuing
years, humanitarian assistance has become more complex and demanding and humanitarian workers have
increasingly sought more education and training in all aspects of relief but especially public health,
development, human rights, and security; with acceptance that humanitarian assistance for many has
become a profession or discipline of its own. Today, 92% of humanitarian workers serving NGOs favor
professionalization[4]. A decade ago about 100,000 people in the aid community considered themselves
as career humanitarian professionals; today this number has risen to more than 220,000 with an annual
rate of increase exceeding 6% per year[4,15]. Both the humanitarian community and those institutions
involved in higher education and training have responded by catalyzing the support and resources needed
to ensure the professionalization process.
Within the humanitarian aid community, strong efforts are underway to provide global and
regional blueprints for the professionalization of humanitarian assistance and its workforce[16]. This
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multidisciplinary process has gained considerable interest and is moving forward rapidly based on
specific obligations for quality performance, education and training, and standards of care discipline-todiscipline. FMTs, like other project teams (e.g., water, sanitation, and sheltering projects), have specific
skills obtained by competency-based education and training that qualify them in each discipline. Health
care workers such as physicians, nurses, dentists, allied health professionals, and laboratory technicians,
among others, also come to the humanitarian community with specific health care degrees and postdegree specialty training. What defines a humanitarian health professional is the combination of these
two competency sets (see Figure 1):
SHARED CORE
HUMANITARIAN
COMPETENCIES
INDIVIDUAL SKILL
SPECIFIC
COMPETENCIES
HUMANITARIAN
PROFESSIONAL
Figure 1. A 'humanitarian health professional' can be defined by the combination of individual skillspecific competencies such as those obtained by a medical or nursing degree and the completion of shared
core competencies that all humanitarian professionals, such as logisticians, project managers, security
personnel, human rights lawyers, and health care workers must possess. (Concept and design of Figure 1
by F.M. Burkle, Jr., Harvard Humanitarian Initiative, Harvard University, Cambridge, MA, 2012)
3. Multidisciplinary Education and Training
In any health emergency, a rapid response by competent physicians and other health professionals is
essential. All health professionals in multiple settings, (eg, hospitals, private practitioners, public health,
community health centers, skilled nursing facilities) have a responsibility to ensure they are prepared to
serve their communities in the event of a disaster. To be effective, education and training requires
consensus on a set of shared competencies, learning objectives, and performance metrics; with course
curricula based on a well-defined and testable body of knowledge and skills[16].
Minimizing adverse health outcomes requires cooperative efforts that cross traditional boundaries
of health specialties, professions, and nationalities. To respond effectively, health professionals,
regardless of specialty or area of expertise, require a fundamental understanding of the disaster
management system and the ways in which various health-related roles are integrated to protect health
and respond to disease or injury. Proficiency requires knowledge and skills beyond those typically
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acquired in clinical and public health training and practice, and must encompass unique competencies.
The delivery of optimal care in a disaster relies on both clinical and public health expertise, and depends
on a common understanding of each health professional’s role in the broader emergency management
system. All health professionals should be knowledgeable about the range of illnesses and injuries that
may arise in a disaster or humanitarian crisis and how their particular expertise facilitates effective
response [16]. In addition, all must be able to recognize the general features of disasters and public health
emergencies and be knowledgeable about their impact on the population, how to report a potential public
health event, and where to access pertinent information as required.
The authors suggest that the following elements should be considered 'essential' components in any
disaster training program for health professionals:
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
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

Personal and family preparedness is crucial to ensure health professionals will report to work
when needed in a disaster. This is most effective when implemented on a systems basis so that
all employees understand roles and responsibilities that fit into a larger framework.
Health professions training should utilize an all-hazards approach, which is systems-oriented and
sustainable.
In response to all hazards, affected populations are best-served by a multidisciplinary approach to
policy, planning, and practice. All health professions and disciplines should be represented in
formulating policy and planning and be trained to function as integrated teams.
All-hazards response requires integration and cooperation across all sectors including public
health agencies, academic/health professions institutions, emergency management services,
community health and service organizations, practitioners, and volunteers.
For training programs to assure that health professionals can perform effectively in a disaster or
public health emergency, curricula need to be 'standardized' and based upon a consensus set of
core competencies with learning objectives related to those competencies.
All-hazards training for health professionals must anticipate the particular needs of underserved
and other vulnerable populations in disasters with locally relevant and socially and culturally
sensitive planning and practices.
To engage health professionals in all-hazards training, the training must be accessible, acceptable,
adaptable, time-efficient, cost-effective, evidence-based, and customized to the needs of learners
and the communities they serve.
Education and training in disaster preparedness should be flexible and convenient, which requires
a variety of learning modalities (e.g., classroom, web based, exercises, drills).
To encourage participation of health professionals in all-hazards training programs, incentives
such as continuing education credits or professional certifications are desirable.
Systematic evaluation of program effectiveness is needed on a regular basis, with modification of
training approaches as needed to achieve successful process measures and outcomes.
4. Disaster and Crisis-Specific Competencies
Humanitarian health workers are integrated under shared core humanitarian competencies with education
and training for general health care providers. Core humanitarian competency education and training is
traditionally provided by established non-governmental agencies (eg, MSF, ICRC) as well as established
academic affiliated training centers throughout the world. For example, North America (USA and
Canada) is fortunate to have 12 such centers that have offered competency-based training for 3 to 17
years. All of these programs train both civilian and military students on a regular basis. Similar
opportunities exist or are being developed on all continents [16].
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Core competencies provide the fundamental basis of collective learning and help ensure
consistent application and translation of knowledge into practice. In 2007, recognizing the need to better
integrate competencies across all health specialties and professions, an expert stakeholder group was
convened to develop a consensus-based educational framework and competency set from which educators
could devise learning objectives and curricula in disaster medicine and public health[17]. This
competency set, adopted by the National Disaster Life Support Education Consortium™ in 2008, and
served as the basis for an extensive revision of the National Disaster Life Support™ training courses[see
http://www.ndlsf.org]. In 2012, the results of a similar process was published that focused on the
integration of cross-cutting competencies applicable to most, if not all, potential health system
responders[18]. This effort delineated core competencies and associated sub-competencies on which to
create a standard, baseline core curriculum for all potential health system responders. Additionally,
separate subdiscipline-specific competencies (e.g., emergency surgery, tropical medicine, anesthesia,
critical care, pediatrics, mental health in resource poor countries, among others) and courses are available
both regionally and internationally (eg, MSF and ICRC Emergency Surgery courses, American Academy
of Pediatrics' sponsored "Children & Disasters" training program for use in international/developing
countries).
Existing centers of learning and practitioners of aid have collaborated to develop competencies
that form the foundational basis of curriculum and course development.(see Tables 1 and 2) While all
published competencies are similar in many areas, they may differ in emphasis of specific discipline or
professional skill requirements over those of others. As such, competencies exist for skills related to
disaster medicine, nursing, and emergency medical services (EMS) professionals for single event
disasters at a national level, others focus primarily on public health emergencies and preparedness,
whereas others strictly focus on international humanitarian crises in resource poor countries. Core
humanitarian competencies typically emphasize multidisciplinary team requirements that are required by
all professionals not just those in the health care workforce.
Table 1. Representative Competency Sets [16]:
Examples of competency sets that can be used in the development of curricula and courses by
academically-affiliated training centers, non-governmental organizations, and private governmental
organizations. Completion of competency-based training leads to certification of the providers.
All Potential Health System Responders:
• Core Competencies for Disaster Medicine and Public Health[18]
All Health Professionals:
 A Consensus-Based Educational Framework and Competency Set for the Discipline of Disaster
Medicine and Public Health Preparedness[17]
Clinicians and EMS Professionals
• National Standardized All-Hazard Disaster Core Competencies for Acute Care Physicians,
Nurses, and EMS Professionals: Schultz CH, Koenig KL, Whiteside M, et al. Annals of
Emergency Medicine. 2012;59(3):196-209.
Public Health Professionals:
• Public Health Preparedness and Response Core Competency Model. Final Model Version. 1.0.
Centers for Disease Control and Prevention and the Association of Schools of Public Health;
December 17, 2010. Retrieved from
http://www.asph.org/userfiles/PreparednessCompetencyModelWorkforce-Version1.0.pdf.
• Association of Schools of Public Health. Global Health Competency Model. Final Version 1.1;
October 31, 2011. Retrieved from
http://www.asph.org/userfiles/Narrative&GraphicGHCompsVersion1.1FINAL.pdf.
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Humanitarian Assistance Professionals:
• Establishing Common Competencies and Leadership Frameworks. London. United Kingdom:
Consortium of British Humanitarian Agencies (CBHA); 2010. Retrieved from
http://www.thecbha.org/media/website/file/CBHA_Competency_Frameworks.pdf.
• Network on Humanitarian Assistance International Association of Universities (NOHA).
Professional Profiles and Competencies. Retrieved from http://www.nohanet.org/noha-masterprogramme/professional-profiles-and-competencies-.html.
Table 2. Consensus-Derived Core Competencies for All Potential Health System Responders[18]
Core Competency
1.0 Demonstrate personal and family preparedness for disasters and public health emergencies.
2.0 Demonstrate knowledge of one’s expected role(s) in organizational and community response plans
activated during a disaster or public health emergency.
3.0 Demonstrate situational awareness of actual/potential health hazards before, during, and
after a disaster or public health emergency.
4.0 Communicate effectively with others in a disaster or public health emergency.
5.0 Demonstrate knowledge of personal safety measures that can be implemented in a disaster or
public health emergency.
6.0 Demonstrate knowledge of surge capacity assets, consistent with one’s role in organizational,
agency, and/or community response plans.
7.0 Demonstrate knowledge of principles and practices for the clinical management of all
ages and populations affected by disasters and public health emergencies, in accordance
with professional scope of practice.
8.0 Demonstrate knowledge of public health principles and practices for the management of
all ages and populations affected by disasters and public health emergencies.
9.0 Demonstrate knowledge of ethical principles to protect the health and safety of all ages,
populations, and communities affected by a disaster or public health emergency.
10.0 Demonstrate knowledge of legal principles to protect the health and safety of all ages,
populations, and communities affected by a disaster or public health emergency.
11.0 Demonstrate knowledge of short- and long-term considerations for recovery of all ages,
populations, and communities affected by a disaster or public health emergency.
Figure 2 depicts four proficiency levels of health professionals in disaster medicine and public health as
correlated with their expected role in a disaster. The baseline or floor-level competencies are intended to
serve as the foundation for the more specific competencies developed by other entities. Second level
competencies are those required by the institutions, organizations, and agencies in which health
professionals work each day. Third level competencies apply to some – but not all – members of the
health disciplines and professions that require more specialized knowledge and skills in disaster-related
medicine and public health (eg, emergency medical and nursing personnel). The tip of the pyramid
contains the very specific competencies expected of health personnel who comprise various disaster
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response teams, including FMTs. As depicted in Figure 2, competencies become more specialized as an
individual moves up the pyramid, but everyone starts at the same base level of proficiency.
Figure 2. Defining the Audience: A Multi-tiered and Multidisciplinary Learning Framework
•
HighlySpecialized
Competencies
Highly specialized and integrated
competencies for regularly deployed
responders
•
•
•
•
National Disaster Medical System
Teams (DMAT/DMORT)
US Public Health Service Teams
FMTs
Doctors Without Borders/ Médecins
Sans Frontières
Clinical fellowships
Discipline/Profession
Specific Competencies
Members of the health disciplines and professions
that require more specialized knowledge and skills
in disaster–related medicine and public health
Role/Function/Category Specific Competencies
• Hospital workers • Healthcare workers
• Medical Reserve Corps • Health profession students •
• Humanitarian aid workers • Public health workers •
Additional competencies required for expected roles in the healthcare facility,
public health agency, or other practice or community response organization
Core Competencies for All Potential Health
System Responders
Source: Adapted from Reference 18.
5. Global Support Networks
Several sector-wide networks have developed over recent years, for example the Active Learning
Network for Accountability and Performance (ALNAP) made up of international humanitarian
organizations promotes successful means to enhance quality performance among NGOs. A network
called ELRHA (Enhancing Learning and Research for Humanitarian Assistance) is a new collaborative
network dedicated to supporting partnerships between higher education institutions and humanitarian
organizations and partners around the world[4]. The ELRHA Project moves the professionalization of
humanitarian aid workforce from "discussion to action" [19]. The EHRHA network consists of Regional
HUBS (currently active are those from East Africa, Europe, United Kingdom, and North America[20];
see Figure 3).
Figure 3. The EHRHA HUB Network: One 'HUB' site has been allocated per active HUB. Adapted
from http://www.elrha.org/work/professionalisation/hubs.
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REGIONAL HUBS
Within these HUBs are educational and training projects and programs to professionalize not only health
providers but also logisticians, security managers, humanitarian law experts, human resources
professionals and many others that support life-saving assistance projects in water, sanitation, health,
shelter, food and energy. It is being encouraged that worldwide actions take place between existing HUB
training centers in developed countries and those struggling to sustain such expertise in developing
countries, the goal being to ensure regionally appropriate and culturally sensitive education and training
curricula and courses leading to certification in humanitarian assistance on all continents. The process of
organizing education and training centers within regional HUBS should consider the following [21]:
1. Expectations are that each discipline, such as medicine, law, logistics, and security would
determine and demonstrate discipline-specific competency-based education and training. This
would be completed based on regional and cultural standards as global HUBS.
2. The HUBS would establish recognized certified training programs and work with members,
academics, and training institutions to devise certification criteria for entry-, mid- level and
higher levels of members obtaining the training.
3. The Regional Hubs would provide accredited trainers from accredited academic affiliated training
centers. Trainers would become accredited via their training institutions and or by supervised
experience in humanitarian missions and a track record of teaching the competency-based
curriculum content and courses.
4. After creating a list of competencies, both core humanitarian competencies (that all humanitarian
workers need to know) and discipline specific ones (required by the professional specialty), the
regional HUBS would devise the routes for certification of the people they trained. This most
commonly comes from individuals completing a specified curriculum, demonstrating competency
through examination or experience, and experienced workers who provide a portfolio or 'pass
port' to document the acquisition of competencies through previously completed FMT services.
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5. Ideally, accredited training centers regionally would organize themselves under Professional
Associations of Accredited Academic Training Centers in Humanitarian Health (or emergency
surgery, tropical medicine, humanitarian pediatrics, mental health, etc.) to ensure timely and
accurate updates in educational advances, share relevant information, determine common data
impact documentation and reporting standards, devise commonly accepted competencies to meet
new education challenges, and provide advocacy efforts worldwide.
6. Registry of Certified Humanitarian Health Providers
As the professionalization process matures, a registry of certified providers needs to be developed.
Regional HUB-accredited training centers would seek recognition from the humanitarian stakeholders
(NGOs, IOs, Donors, etc) whose interest is to recognize and support the professionalization process of the
FMTs and accept the certification it provides[19]. The process leading to recognized academic
associations for individual professional disciplines is summarized as [21]:
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Organize independent 'discipline-specific' professionals regionally
Establish a forum for the development of core humanitarian and core discipline-specific
competencies
Set professional and ethical standards
Accredit training centers and trainers
Establish discipline-specific routes to certification
Promote research agendas to build curriculum content and standards of care
Internationalize the field (among like-minded regional HUBS)
Individual volunteers to humanitarian missions as well as those organized under NGO health services
delivery organizations (eg, ICRC, MSF, International Medical Corps) would benefit equally under this
format of professionalization. It should be clear that the obligation that all health care providers have is to
ensure they have the competencies to do what they are expected to do.
7. Closing Comment
Sustained efforts, including those described in this paper, are needed to establish and maintain a
humanitarian health workforce that possesses the knowledge, skills and abilities to support all healthrelated aspects of disaster management. Formal education and training can enhance the ability of all
potential health system responders to be useful in an emergency as volunteers or as members of wellestablished organizations with significant disaster expertise. Additional research is necessary to identify
the extent to which these efforts are integrated into current academic and professional development
programs within the health sciences, what gaps exist in achieving these standards within current curricula,
and what mechanisms exist or need to be developed to fill identified gaps. Future collaborative efforts to
create and refine education and training curricula in disaster-related medicine and public health should
integrate the multi-tiered and multi-disciplinary learning framework proposed in this paper together with
foundational core competencies as a global standard.
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